Five-year Recurrence-free Survival After Surgery Followed by Oral Chemotherapy for Gastric Cancer With Portal Vein Tumor Thrombosis.

Gastric cancer with portal vein tumor thrombosis (GC-PVTT) is a rare condition with a very poor prognosis. A 64-year-old man with GC-PVTT was admitted to our hospital. His carcinoembryonic antigen level was slightly elevated (17.4 ng/ml). Upper gastrointestinal endoscopy showed a type-2 gastric lesion (45 mm × 40 mm) in the gastric antrum. The PVTT originated from the main gastric tumor and continued to the superior mesenteric vein. Fluorodeoxyglucose-positron emission tomography showed high uptake both by the main tumor and PVTT. A distal gastrectomy with D2 lymphadenectomy was performed with simultaneous removal of the PVTT. Pathological examination showed a poorly differentiated adenocarcinoma with neuroendocrine differentiation. Adjuvant chemotherapy with S-1 was administered for 1 year. The patient survived for >5 years with no recurrence. Surgical gastrectomy and complete removal of the PVTT followed by S-1 chemotherapy could be a treatment option that offers improved long-term survival for patients with GC-PVTT.

Reduced iodinated contrast media for abdominal imaging by dual-layer spectral detector computed tomography for patients with kidney disease.

Contrast-enhanced computed tomography using iodinated contrast media is useful for diagnosis of gastrointestinal diseases. However, contrast-induced nephropathy remains problematic for kidney diseases patients. Although current guidelines recommended the use of a minimal dose of contrast media necessary to obtain adequate images for diagnosis, obtaining adequate images with sufficient contrast enhancement is difficult with conventional computed tomography using reduced contrast media. Dual-layer spectral detector computed tomography enables the simultaneous acquisition of low- and high-energy data and the reconstruction of virtual monochromatic images ranging from 40 to 200 keV, retrospectively. Low-energy virtual monochromatic images can enhance the contrast of images, thereby facilitating reduced contrast media. In case 1, abdominal computed tomography angiography at 50 keV using 40% of the conventional dose of contrast media revealed the artery that was the source of diverticular bleeding in the ascending colon. In case 2, ischemia of the transverse colon was diagnosed by contrast-enhanced computed tomography and iodine-selective imaging using 40% of the conventional dose of contrast media. In case 3, advanced esophagogastric junctional cancer was staged and preoperative abdominal computed tomography angiography could be obtained with 30% of the conventional dose of contrast media. However, the texture of virtual monochromatic images may be a limitation at low energy.

A case of malignant peritoneal mesothelioma suggesting the utility of combining double-contrast radiography and endoscopy with computed tomography for diagnosis.

A 68-year-old woman presented with abdominal pain, weight loss, and vomiting. Enhanced computed tomography (CT) showed slightly increased density in the mesentery and edema of the third portion of the duodenum and proximal jejunum. Little ascites, but no primary lesion, lymph node metastases, or distant metastases, were observed. Endoscopic findings included erythema and edema in the distal duodenum and proximal jejunum without epithelial lesions. Double-contrast radiography revealed transverse ridging with convergence, suggesting a serosal lesion. We suspected disease involving the serosa, such as mesenteric panniculitis. However, the lesion was definitively diagnosed as malignant peritoneal mesothelioma based on a biopsy specimen obtained at laparotomy. The combination of transverse ridging with convergence on double-contrast radiography and mucosal edema without epithelial lesions on endoscopy was consistent with a disorder involving the serosa. Transverse ridging with convergence is helpful to diagnose serosal pathology such as malignant peritoneal mesothelioma. Combining the findings of double-contrast radiography and endoscopy with computed tomography may facilitate diagnosis of malignant peritoneal mesothelioma. Thus, in case of increased density of mesentery and wall thickness on CT image with transverse ridging with convergence on double-contrast radiography and without epithelial lesion on endoscopy, malignant peritoneal mesothelioma must be considered.

Extracapsular extension of prostate cancer: diagnostic value of combined multiparametric magnetic resonance imaging and isovoxel 3-dimensional T2-weighted imaging at 1.5 T.

OBJECTIVE: The objective of this study was to assess whether adding isovoxel 3-dimensional T2-weighted imaging (volume isotropic T2-weighted acquisition [VISTA]) to multiparametric magnetic resonance imaging (mp-MRI) improves the ability to diagnose the extracapsular extension (ECE) of prostate cancer. METHODS: Two radiologists independently evaluated ECE on images acquired with mp-MRI only (method A) and mp-MRI plus VISTA (method B) in 50 men who had undergone prostatectomy. We also compared the signal-to-noise ratio of the tumor on T2WI and VISTA scans. RESULTS: Sensitivity, specificity, and accuracy were higher with method B. For both readers, specificity, accuracy, and the area under the receiver operating characteristic curve of method B were significantly higher than those of method A (reader 1: P = 0.028, 0.025, and 0.006; reader 2: P = 0.017, 0.0071, and 0.018). The signal-to-noise ratio was significantly higher on T2-weighted imaging than VISTA images (9.21 [SD, 2.46] vs 7.30 [SD, 1.87], P < 0.01). CONCLUSIONS: The addition of VISTA to mp-MRI improves the diagnostic value for ECE significantly.

Clinical utility of the normalized apparent diffusion coefficient for preoperative evaluation of the aggressiveness of prostate cancer.

PURPOSE: Normalization of the apparent diffusion coefficient (ADC) may overcome ADC variability attributable to different patient and/or technical factors. The purpose of this study was to compare the efficacy of ADC and the normalized ADC (nADC) for differentiating between prostate cancer with a Gleason score (GS) = 6 and GS > 6 and to identify an optimum reference for nADC calculations. MATERIALS AND METHODS: Our study population comprised 58 patients who underwent diffusion-weighted MRI followed by radical prostatectomy. The nADC of the prostate cancer was calculated as ADC (cancer)/ADC (reference) by using the obturator internus muscle, urine in the bladder, and a 20-ml saline bottle placed on the groin as references. We performed receiver operating characteristic (ROC) analysis to identify the optimum reference for nADC calculations. RESULTS: To differentiate between GS = 6 and GS > 6 prostate cancer, the area under the ROC curve of the nADC obtained with a saline bottle as reference was best (0.85) and significantly better than the area under the ADC ROC curve (0.71). CONCLUSIONS: nADC is superior to ADC for estimating the aggressiveness of prostate cancer. It is a noninvasive technique that aids in the selection of appropriate treatments.

[Methotrexate-related lymphomatoid granulomatosis in a patient with rheumatoid arthritis].

A 76-year-old man who was taking prednisolone and methotrexate for rheumatoid arthritis presented with gastric ulcers. Chest X-ray images showed multiple pulmonary nodules. Transbronchial lung biopsy specimens showed lymphocytic infiltrates but no malignant cells. The radiographic findings gradually ameliorated over a month, but then deteriorated 5 months later. We performed video-assisted thoracoscopic biopsy of the left lung, and the biopsy specimens showed lymphocytic infiltration with necrosis, in which the atypical lymphocytes were positive for Epstein-Barr virus-encoded small RNAs in situ hybridization (EBER-ISH). A diagnosis of lymphomatoid granulomatosis was determined. One year before this diagnosis, the patient was found to have an inflammatory liver tumor that had disappeared spontaneously within a month. A new pathological review of the liver and stomach lesions demonstrated EBER-ISH-positive lymphocytes, and therefore we assumed that they were pathological features of lymphomatoid granulomatosis. The chest radiographic findings improved gradually after the discontinuation of methotrexate. We therefore suggest that methotrexate treatment may be associated with the development of lymphomatoid granulomatosis in patients with rheumatoid arthritis. Lymphoproliferative disorders, including lymphomatoid granulomatosis, should be considered in patients with rheumatoid arthritis who are receiving methotrexate.

Ultra-high-b-value diffusion-weighted MR imaging for the detection of prostate cancer: evaluation in 201 cases with histopathological correlation.

PURPOSE: To assess the diagnostic performance of diffusion-weighted magnetic resonance (MR) imaging (DWI) for prostate cancer detection, using different b-values. METHODS: A total of 201 patients who underwent MR imaging before total prostatectomy were evaluated. MR images were independently assessed by three radiologists. Three combinations of sequences were separately evaluated, as follows: group 1 [T2-weighted images (T2WI) alone], group 2 (T2WI and DWI with a b-value of 1,000 s/mm2), group 3 (T2WI and DWI with a b-value of 2,000 s/mm2). Whole-mount-section histopathological examination was the reference standard. Areas under the receiver operating characteristic curve (AUCs) and diagnostic performance parameters were determined. RESULTS: The sensitivity, specificity, and AUC for the detection of prostate cancer were as follows: 52.2%, 80.7%, and 0.694 in group 1; 61.2%, 82.6%, and 0.755 in group 2; 73.2%, 89.7%, and 0.842 in group 3. Group 3 achieved the highest diagnostic performance, followed by group 2 (P<0.05). In the transition zone, the specificity was lower (P<0.001) for group 2 (82.2%) than for group 1 (86.2%). CONCLUSION: The addition of diffusion-weighted images with a b-value of 2,000 s/mm2 to T2WI can improve the diagnostic performance of MR imaging in prostate cancer detection.

Pulmonary artery obstruction due to a metastatic malignant phyllodes tumor of the breast.

A 65-year-old woman with a 9-year surgical history of a left breast phyllodes tumor was admitted with progressive chest pain on effort. Computed tomography showed severe stenosis of the main pulmonary artery, with the mass originating from the ventricular septum. We planned to resect the tumor the next day. However, the next morning a pulmonary artery embolism occurred, and she developed dyspnea and lost consciousness. After carrying out cardiopulmonary resuscitation, we performed a life-saving operation. We successfully resected the huge tumor as far as possible from the right ventricle via a right atrial (RA)-tomy. However, her consciousness did not improve to better than Glasgow Coma Scale grade 7. She died from suffocation caused by metastasis invading her airway despite undergoing tracheotomy on the 77 th postoperative day.

[A case of bronchial glomus tumor].

A 67-year-old man was admitted to our hospital because of a cough and hemoptysis. Chest CT and bronchoscopy demonstrated a polypoid tumor in the truncus intermedius. The pathological diagnosis of the biopsy specimens was glomus tumor, which is an extremely rare tumor of the respiratory tract. We performed a successful bronchoscopic removal of the tumor using a high-frequency-wave snare and microwave coagulation. After one year of follow-up, there was no recurrence. To the best of our knowledge, this is only the 24th report of a tracheobronchial glomus tumor.

[A case of lymphomatoid granulomatosis].

An 83-year-old man was found to have multiple pulmonary nodules and ground-glass opacities after a left upper lobectomy for non-small-cell lung cancer. After bronchoalveolar lavage and transbronchial lung biopsy, he was put on a regimen of steroids for a tentative diagnosis of organizing pneumonia. Over the course of 3 months, the radiographic findings improved; however, they progressively deteriorated during the steroid tapering period and new skin lesions also appeared. Skin biopsy specimens showed lymphohistiocytic infiltration in which the atypical lymphocytes were positive for EBV encoding small RNAs by in situ hybridization; we therefore diagnosed lymphomatoid granulomatosis. The pulmonary and cutaneous lesions responded to steroid and cyclophosphamide therapy, but the patient died unexpectedly due to a rapid onset of massive pulmonary thromboembolism.

Usefulness of diffusion-weighted imaging in the localization of prostate cancer.

PURPOSE: Advances in high-precision radiation therapy techniques for patients with prostate cancer permit selective escalation of the radiation dose delivered to the dominant intraprostatic lesion and improve the therapeutic ratio. We evaluated the value of diffusion-weighted imaging (DWI) for dominant intraprostatic lesion assessment. METHODS AND MATERIALS: The study population consisted of 23 patients with early prostate cancer. Before undergoing total prostatectomy, they were evaluated by means of magnetic resonance imaging, including DWI. T2-weighted imaging (T2WI) with and without DWI were retrospectively assessed by six independent observers. Imaging findings were compared with pathologic results from whole prostate specimens on a lesion-by-lesion basis. RESULTS: Pathologic study identified 43 lesions in 23 patients. On magnetic resonance imaging, the six observers correctly identified 11-22 of 43 lesions (sensitivity, 26-51%) on T2WI alone and 20-31 (sensitivity, 47-72%) on T2WI plus DWI. Positive predictive values were 42-73% on T2WI alone and 58-80% on T2WI plus DWI. For all observers, detection was higher on combined T2WI and DWI than on T2WI alone. CONCLUSION: Because the addition of DWI to T2WI improves the detectability of prostate cancer, DWI may offer a promising new approach for radiation therapy planning.

Successful treatment of primary pulmonary angiosarcoma.

Angiosarcoma in the lung is an uncommon disorder and is usually attributable to metastasis from a primary site. Primary pulmonary angiosarcoma is extremely rare, and the prognosis of affected individuals is dismal, with most patients dying within months of presentation. Indeed, there have been no reported instances of successful treatment of this condition. We now report the case of a patient with primary pulmonary angiosarcoma who responded to a combination of radiotherapy and immunotherapy with recombinant interleukin-2. The patient remains well without signs of recurrence 1 year after initial presentation. This combination therapy may be a promising strategy to prolong the survival of patients with primary pulmonary angiosarcoma.

Increased expression of monocyte chemoattractant protein-1 in atherectomy specimens from patients with restenosis after percutaneous transluminal coronary angioplasty.

The plasma concentration of monocyte chemoattractant protein-1 (MCP-1) antigen is higher in patients with restenosis after coronary angioplasty than in those who do not restenose. In this study the MCP-1 expression of coronary atherectomy specimens was investigated by immunohistochemistry. Samples were obtained from 12 patients with restenosis and 15 with de novo lesions by directional coronary atherectomy. MCP-1 immunoreactivity was found in all patients in the restenosis group and in 8 of the de novo group. The frequency of macrophage expression was higher in the restenosis group than in de novo group. These results indicate that local expression of MCP-1 may be associated with the mechanisms of vascular remodeling after coronary angioplasty.

Immunohistochemical expression of SKALP/elafin in squamous cell carcinoma of human lung.

The immunohistochemical expression of skin-derived anti-leukoproteinase (SKALP)/elafin in lung squamous cell carcinoma (SqCC) and in uninvolved bronchial epithelium was studied. The results were compared with the immunohistochemical staining of proliferating cell nuclear antigen (PCNA) and the TDT-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay. SKALP/elafin was expressed in SqCC with high incidence (82.6%). By contrast, the expression was not observed in uninvolved bronchial epithelium. SKALP/elafin expression was located in the cell layers just underneath the cornified envelope of each cell nest, and DNA fragmentation was observed in the same cell layers. PCNA was expressed in the basal layer of each cornified envelope, and both expressions were clearly separated. Immunoreactive score of SKALP/elafin expression was significantly correlated with the differentiation and it tended to increase in accordance with the degree of differentiation. These results suggested that SKALP/elafin was possibly involved in the cell differentiation program, finally leading to keratinization in SqCC of human lung. SKALP/elafin may be a beneficial molecular target for detection or even the development of a new therapeutic method against cancer.

Quantitative analysis of type IV collagen alpha chains in the basement membrane of human urogenital epithelium.

Type IV collagen is a major component of the basement membrane (BM), which consists of six genetically distinct alpha(IV) chains. In this study the expression of these six alpha(IV) chains was demonstrated immunohistochemically. In addition, the alpha2(IV) and alpha5(IV) chains were analysed quantitatively by confocal laser scanning microscopy in human urogenital epithelial BM. The alpha1/alpha2(IV) and alpha5/alpha6(IV) chains were immunoreactive in the epithelial BM, whereas, alpha3/alpha4(IV) chains were not. The quantitative analysis revealed that the amount of alpha2(IV) and alpha5(IV) chains differed in each urogenital epithelial BM. The content of alpha5(IV) chains in the epithelial BM of the bladder was differentially high, and that of the foreskin was differentially low. It is concluded that the elasticity of epithelial BM of the bladder may be structurally related to the high content of alpha5/alpha6(IV) chains.